Life Experiences in Neuromuscular Tracheotomized Patients in Times of Covid-19.

BACKGROUND: The management of tracheotomy at home can be very complex, affecting the patient's quality of life. OBJECTIVES: This case series study aimed to explore the experiences of patients affected by neuromuscular diseases (NMD) concerning tracheostomy and Invasive Mechanical Ventilation (IMV) management at home during the COVID-19 health emergency in Italy. METHODS: Semi-structured interviews and the following instruments were used: Connor and Davidson Resilience Scale (CD-RISC-25); Acceptance and Action Questionnaire-II (AAQ-II); State-Trait Anxiety Inventory (STAI); Langer Mindfulness Scale (LMS). Descriptive analyses, correlations, and qualitative analyses were carried out. RESULTS: 22 patients [50% female, mean age = 50.2 (SD = 21.2)] participated in the study. Participants who showed high levels of dispositional mindfulness in terms of novelty-seeking (r = 0.736, p = 0.013) and novelty production (r = 0.644, p = 0.033) were those with higher resilience. The main emotion that emerged was the fear of contagion (19 patients, 86.36%), due to the previous fragile condition, leading to a significant sense of abandonment. The tracheostomy's perception is seen in extremes as a lifesaver or a condemnation. The relationship with the health professionals moves from satisfaction to a feeling of abandonment with a lack of preparation. CONCLUSIONS: The relationship between resilience, flexibility, state anxiety and dispositional mindfulness offers ways to reinforce tracheostomy management at home, even in critical periods when going to the hospital may be difficult.

COVID-19 convalescent plasma: Mechanisms of action and rationale for use: A narrative review

The use of convalescent plasma (CP) transfusions for patients with coronavirus disease 2019 (COVID-19) has gained great interest during the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic. This review aims at summarizing the literature on the potential mechanisms of action of COVID-19 CP (CCP) and the rationale for use. A narrative review of the literature was conducted using PubMed, Google Scholar, and the Cochrane Database through October 2020. The rationale of CCP deployment was based on historical use in other outbreaks and pandemics and the emergent need at the time of lack of proven therapies and vaccines. There are many proposed mechanisms of action including direct neutralization and suppression of viremia, antibody-dependent cellular cytotoxicity, modification of the inflammatory response, restoration of the coagulation factors, immunomodulation of the hypercoagulable state and the potential role of ABO naturally occurring iso-agglutinins. Many donor, product, and patient factors can impact the response to CCP, such as antibody titer in the CCP product, CCP dose, frequency of administration, the severity of underlying illness, and the timing of administration from time of disease onset. Based on current evidence, CCP appears to be safe. However, it remains unknown whether it impacts the improvement of clinical symptoms, time to death, and all-cause mortality. In conclusion, the use of CCP offers quick access as an empirical therapy when specific therapies are not available or under development. Ongoing clinical trials are expected to add to the breadth of knowledge on the safety and efficacy of CCP use in patients with COVID-19.Copyright © 2021 AME Publishing Company.

Home oxygen therapy : A suitable modality for critically ill COVID-19 patients after discharge

Tunisia, like many countries, was confronted to the unprecedented COVID-19 pandemic. Home oxygen therapy, classically proposed for chronic respiratory insufficiency, was a real solution to high pressure on health system. to evaluate feasability and safety of home oxygen therapy after discharge from intensive care unit (ICU) in severely ill COVID-19 patients. we conducted a prospective, observational, single- center study between October 2020 and December 2021. We included patients, with confirmed SARS-CoV-2 pneumonia, requiring home oxygen therapy after their discharge from intensive care unit of Zaghouan's Hospital (Tunisia). Home oxygen therapy is offered to eligible patients after clinical improvement and still requiring nasal oxygen therapy less than 6 L/min. After their consent, patients and their caregivers were instructed on using concentrator and monitoring pulse oxygen saturation. A daily telephone follow-up was fulfilled. Twenty patients were enrolled. Median age was 54.5 [28-68] years, 60% pas de pourcentage si nb inf a30 were male. At least one comorbidity was observed in 11/20 patients. Hypertension (7/20), COPD (4/20) and diabetes mellitus (3/20) were the most common associated risk factors. Among the cohort and during their hospital stay all patient were under mechanical ventilation. Median length of ICU stay was 14 [2-33] days. Median rate of oxygen flow, at the moment of hospital discharge, was 2.9 [2-5] L/min. Oxygen therapy was required for a median of 26 days [6-90]. No deaths or urgent unplanned hospitalization were reported during the follow-up period. Early discharge of oxygen-requiring COVID-19 patients after an ICU stay was safe and effective.

Efficacy and safety of high-flow nasal cannula therapy in elderly patients with acute respiratory failure.

INTRODUCTION: To assess the efficacy and safety of high-flow nasal cannula (HFNC) in elderly patients with acute respiratory failure (ARF) not due to COVID-19, refractory to treatment with conventional oxygen therapy and/or intolerant to noninvasive ventilation (NIV) or continuous positive airway pressure (CPAP) and without criteria for admission to intensive care units (ICU). METHODS: Prospective observational study of patients with ARF treated with HFNC who presented clinical and arterial blood gas deterioration after 24 h of medical treatment and oxygenation by conventional systems. The degree of dyspnoea, gas exchange parameters (arterial O2 pressure/inspired O2 fraction ratio (PaO2/FiO2); oxygen saturation measured by oximetry/ inspired fraction of oxygen (Sp02/Fi02), ROX index), degree of patient tolerance and mortality were evaluated. These were measured at discharge from the emergency department (ED), 24 h after treatment with conventional oxygenation and 60, 120 min and 24 h after initiation of HFNC. The results were analyzed for all patients as a whole and for patients with hypercapnia (arterial carbon dioxide tension (PaCO2) < 45 mmHg) separately. RESULTS: 200 patients were included in the study between November 2019 and November 2020, with a mean age of 83 years, predominantly women (61.9%), obese (Body Mass Index (BMI) 31.1), with high comorbidity (Charlson index 4) and mild-moderate degree of dependence (Barthel 60). A number of 128 patients (64%) were hypercapnic. None had respiratory acidosis (pH 7.39). Evaluation at 60 min, 120 min and 24 h showed significant improvement in all patients and in the subgroup of hypercapnic patients with respect to baseline parameters in respiratory rate (RR), dyspnoea, ROX index, PaO2/FiO2, SpO2/FiO2 and patient comfort. No changes in PaCO2 or level of consciousness were observed. HFNC was well tolerated. Ten patients (5%) died due to progression of the disease causing ARF. CONCLUSIONS: HFNC is an effective and safe alternative in elderly patients with ARF not due to COVID-19, refractory to treatment with conventional oxygen therapy and/or intolerant to NIV or CPAP and without criteria for admission to ICU.

Spontaneous knee hemarthrosis associated with enoxaparin treatment in a post covid 19 patient

Purpose: To report a case of a 66-year- old Filipino male who developed spontaneous knee hemarthrosis following enoxaparin prophylaxis. Method(s): Case report Result: Case: We report a case of a 66-year- old Filipino male who developed spontaneous hemarthrosis of the left knee following enoxaparin use as venous thromboembolism prophylaxis. Pertinent in the medical history was the diagnosis of chronic kidney disease and chronic respiratory failure as sequelae of COVID 19 infection. During the course of admission, the patient developed acute pain and swelling of the left knee. He was bedridden and no prior traumatic events were noted. Coagulation parameters were within normal range. Arthrocentesis revealed viscous hemorrhagic synovial fluid (25 ml) with fluid analysis showing predominance of red blood cells (Red blood cells: 680,000/muL, White blood cells: 7200/muL) with no crystals seen on polarizing microscopy. Microbial culture was negative. Intravenous methylprednisolone was given and enoxaparin was continued. One day post arthrocentesis, there was improvement of pain and joint function. Joint swelling resolved. Patient had no recurrence of joint pain and swelling. Ethical consideration: Informed consent for both written and photographic content was secured and patient confidentiality was observed. Conclusion(s): Our patient is an elderly with chronic kidney disease who recently recovered from COVID 19 infection. He received prophylactic dose of enoxaparin at 40 mg every 24 hours subcutaneously. No other drugs that can affect hemostasis were given. The patient's bleeding parameters were within normal during admission and at the onset of hemarthrosis. We hypothesize that elderly patients with chronic kidney disease receiving low dose enoxaparin may present with spontaneous hemarthrosis even in the absence of trauma. Whether the association between history of recent COVID-19 infection and hemarthrosis is co incidental or causal remains to be elucidated. Prompt aspiration can provide early diagnosis and facilitate proper treatment. (Figure Presented).

Mental health reported in adult invasive home mechanical ventilation through a tracheostomy: A scoping review

Background: Although people receiving invasive home mechanical ventilation through a tracheostomy are facing both physical and mental health challenges, healthcare services often focus mainly on physical symptoms. To ensure well-functioning treatment and care for people receiving tracheostomy ventilation in a home setting, their mental health needs to be promoted and seen as an integral part of their health in general. Objective: This scoping review aimed to provide a summary of the current knowledge on the mental health of people receiving invasive home mechanical ventilation through a tracheostomy. Design: A scoping review of published and gray literature based on the framework developed by Arksey and O'Malley and refined by the JBI was performed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews checklist was used for reporting the findings. Methods: A literature search was conducted by two researchers independently in the PubMed, CINAHL and PsycINFO databases. Additional searches for gray literature were conducted in Google, Google Scholar, websites of selected organisations, and the reference lists of included studies. The software system Covidence was used in the study selection process. For critical appraisal, the Mixed Methods Appraisal Tool was used. Results: Thirteen studies were included in this review, of which six used qualitative, six quantitative, and one mixed methods. The majority of studies were authored in Europe (n = 10), followed by the Americas (n = 2) and the Western Pacific (n = 1). Mental health was investigated both directly and indirectly (61.5% vs. 38.5%). Categorizing the reported mental health outcomes, we found that emotional well-being was reported widely across the studies (n = 13), while psychological well-being (n = 5) and social well-being (n = 4) were less widely reported. Conclusions: The mental health of people receiving home tracheostomy ventilation has received some scholarly attention. A heterogeneity of mental health outcomes was reported in the literature with emotional well-being being an important mental health area both in relation to the sub-components positive affect and quality of life appraisal. Mental health outcomes in relation to psychological well-being and social well-being were fragmented and only sparsely investigated. © 2022 The Author(s)

A Rare Case of T-Cell Chronic Active Ebstein-Barr Virus (Caebv) Complicated by Development of Hemophagocytic Lymphohistiocytosis (Hlh), T Cell Lymphoproliferative Disorder (Lpd) and Ebv Meningitis

Background: T-cell chronic active Epstein-Barr virus infection (CAEBV) is a rare disease in which patients have the Epstein-Barr virus (EBV) present mainly in the T-cells, which infiltrate tissues like the liver, and bone marrow. Patients eventually develop liver failure, hemophagocytic lymph histiocytosis (HLH), coronary artery aneurysms, EBV infiltrating T-cells impairing organ function, or T-cell lymphomas. Prognosis is poor. The current treatment of choice is an allogeneic hematopoietic stem cell transplant. A study by the NIH and Baylor College of Medicine, which reviewed 28 years of data, only found 19 cases of CAEBV. We aim to report a rare case of T-cell chronic active Ebstein-Barr Virus (CAEBV) complicated by the development of HLH and T-Cell LPD. Method(s): A chart review of the CAEBV patient was performed, focusing on disease progression, treatment plans, and complications. Result(s): A 45-year- old Latin American woman from Mexico initially presented with abnormal liver enzymes after taking herbal medications. The patient underwent a liver biopsy and was initiated on prednisone for possible autoimmune hepatitis pending the biopsy report. The liver biopsy showed EBV hepatitis with EBV positive atypical T-cell infiltrate with steatohepatitis and marked steatosis. Prednisone was stopped, and the patient was referred to Hematology. Plasma EBV level was elevated to 3300 IU/mL. The patient was readmitted for sepsis and pancytopenia prior to being seen by Hematology. Bone marrow biopsy showed EBV+T-cell LPD and HLH, and the patient was started on dexamethasone and rituximab. The patient improved, and dexamethasone was weaned off. Subsequently the patient has had numerous hospital admissions for ESBL UTI, CoNS bacteremia, aspiration pneumonia, vocal cord dysfunction, EBV pneumonia, PCP pneumonia, chemotherapy-induced neuropathy, neutropenic fever, chronic respiratory failure and EBV reactivation. The patient underwent multiple rounds of chemotherapy with rituximab and R-CHOP regimen for persistent HLH. In spite of the treatment, the patient developed EBV encephalitis, further complicated by COVID -19 infection. Her family opted for comfort care, and the patient passed away in the hospital. Conclusion(s): Approximately 95% of adults are infected with EBV at some point in their lives and are asymptomatic in most cases. Very rarely do patients develop CAEBV -a life-threatening disease. Allogeneic stem cell transplant should be considered early on in the disease. Unfortunately, our patient had social factors such as lack of insurance and social support that prevented her from getting a timely stem cell transplant. (Figure Presented).

Denosumab in Immobilization-Induced Hypercalcemia

Introduction: Critically-ill patients with prolonged immobility are at risk of hypercalcemia. In ESRD patients with hypercalcemia therapeutic options are limited: Hydration may cause volume overload, loop diuretics are not effective and bisphosphonates may cause over suppression of bone turnover. This case series presents two patients with immobilization-induced hypercalcemia successfully treated with denosumab Case Description: Case 1: a 51 y/o male s/p bilateral lung transplant who developed chronic respiratory failure due to COVID-19. Case 2: a 54 y/o male initially admitted with COVID-19 requiring b/l lung transplant. Both patients developed AKI that progressed to ESRD and were bed bound. Evaluation for the hypercalcemia was compatible with immobilization-induced hypercalcemia: low iPTH, normal 1,25-VitD levels, negative multiple myeloma workup and mildly elevated PTH-rp (due to accumulation of the carboxy-terminal fragments). We eliminated calcium in the enteral feeds, used low calcium dialysis bath without success. Both patients received denosumab 60mg S/c once with improvement of the hypercalcemia. They developed asymptomatic hypocalcemia treated with resumption of calcium in the diet and using a 2.5Ca dialysis bath. Discussion(s): Denosumab is monoclonal antibody to the RANKL that inhibits osteoclast formation. It is currently used in osteoporosis therapy and cancer-induced hypercalcemia. In ESRD patients with immobilization-related hypercalcemia, denosumab offers the advantage of no renal dose adjustment necessary, rapid onset of action and longer therapeutic duration. Patient should be monitored for hypocalcemia, rebound hypercalcemia and risk of over suppression of bone remodeling. (Figure Presented).

Negative Pressure Ventilation for Acute and Acute-on-Chronic Respiratory Failure: A systematic review and meta-analysis

Introduction: Respiratory failure is the most common organ failure seen in the intensive care unit1 and is managed with non-invasive or invasive positive pressure ventilation (PPV). Negative pressure ventilation (NPV) could offer a safe and effective alternative, however existing devices, such as the iron lung, are heavy and access to the patient for ongoing care is a limitation. The COVID-19 pandemic necessitated intense focus on the rapid design and manufacture of new ventilators,2 most of which were positive pressure ventilators. However, new, light-weight negative pressure ventilators were also designed and appeared to be safe and effective in an early trial in healthy human volunteers.3 These devices have the potential to offer patients an alternative to PPV, without the limitations associated with the early negative pressure devices. They are cheaper to manufacture, and importantly, do not require a pressurised gas supply, which may be of particular benefit to countries with less well-resourced healthcare facilities in which acute and acute-onchronic respiratory failure continue to cause significant morbidity and mortality.4 Objectives: To address whether acute or acute-onchronic respiratory failure in hospitalised adults can be safely and effectively managed with NPV. Methods: This systematic review was registered with the international prospective register of systematic reviews (ID CRD420200220881). MEDLINE, EMBASE, CENTRAL, medRxiv, bioRxiv and Trip databases were searched (from inception to 22nd April 2021). Eligible studies included non-intubated hospitalised adults who received NPV in the management of acute or acute on chronic respiratory failure. We included randomised controlled trials, non-randomised studies of intervention and case series. Risk of bias was assessed using three separate tools due to differing study designs. Results: 575 unique citations were screened with 14 meeting inclusion criteria. 1032 acute episodes (888 patients) of respiratory failure were managed with NPV, with 234 receiving PPV as a comparator. The majority (n=845, 66.7%) were treated for an acute exacerbation of COPD. 417 patients from four studies were included in the meta-analysis. The effect of NPV on PaCO2, pH and PaO2/FiO2 was similar to PPV with a mean difference -0.39kPa (95% confidence interval (CI): -0.95, 0.18), 0.01 (95% CI: 0.00, 0.02), and -0.16 (95% CI: -1.98, 1.66) respectively. Of those studies not included in the meta-analysis six showed a statistically significantly increase in PaO2 with the use of NPV and 5 showed a statistically significant improvement in PaCO2. Rates of complications were similar with NPV in those studies that compared it to PPV, and NPV appeared to be well tolerated by patients. This systematic review study was limited by a wide range of study designs. Conclusions: NPV appears to be a safe and effective alternative to PPV in the management of acute exacerbation of COPD. Evidence for its use in other forms of respiratory failure is limited but warrants further investigation.

DUAL MONOCLONAL ANTIBODIES in COVID-19 PATIENTS: CLINICAL and VIROLOGICAL EFFICACY

Background: An emergency use authorization was issued in March 2021 for two combinations of monoclonal antibodies (MAbs) for SARS-CoV-2 infected patients at high risk of severe COVID-19. We performed a cohort study of patients receiving early treatment with Bamlanivimab/Etesevimab (B/E) or Casirivimab/Imdevimab (C/I) in a Paris university hospital. Methods: All patients receiving a MAbs therapy from March to July 2021 were included. Prescriptions were systematically advised by a multidisciplinary team. Both MAbs dual therapies were used up to May 12th, then only C/I due to local emergence of Delta variant. Nasopharyngeal swabs (NPS) were performed at diagnosis and 7 days after infusion. Additional NPS were collected for hospitalized patients at day 3 and during follow-up until negative RT-PCR or patients discharge. Viral sequencing was carried out and viral mutations were retained if present at more than 20% of viral subpopulations. Results: Overall, 66 patients (19 ambulatory) received a MAbs dual therapy for a documented SARS-CoV-2 asymptomatic infection or within 5 days after symptoms onset. Patients had a median age of 67 years [IQR=41-75], 53% were male, 30 (45%) were receiving immunosuppressive treatment (17 being solid organ recipients), 8 (12%) had chronic respiratory insufficiency, and 6 (9%) were receiving chemotherapy. Regarding variants, 82% were Alpha, 5% Delta and 13% other variants. 8 patients (12%) died (6 treated with B/E and two with C/I). Five deaths were related to COVID-19 worsening and three were unrelated. Among the surviving patients, 42 (64%) did not require any oxygen and 16 (24%) required low-flow oxygen. No severe adverse event related to MAbs occurred. A slower viral decay was observed among patients receiving B/E than C/I, with 17/29 and 5/13 having <30 Ct at day 7 post-infusion (p=0.3), respectively, and 9/14 and 1/8 at day 14 (p=0.03). Different Spike mutations emergence were observed including Q493R in 7 patients and E484K in 2 patients, all infected with an Alpha variant, and detected from 6 to 18 days after MAbs infusion. Among the 9 mutations, 8 occurred after B/E infusion and one Q493R occurred after C/I infusions. Conclusion: We described safety and efficacy of early MAbs therapies administration in a cohort of 66 patients at risk of severe COVID-19. Emergence of mutations were observed under both therapies, with increased frequency under B/E. Further studies including patients infected by Delta variant and receiving C/I infusion are ongoing.

Platypnea-orthodeoxia syndrome years after acute pulmonary embolism: Two consecutive cases

Platypnea-Orthodeoxia syndrome (POS) is a rare condition in which dyspnoea and arterial oxygen desaturation are present in the upright position, while in the supine position, they are alleviated. It is observed in the presence of an anatomical (intra-or extracardiac) communication between the right and left heart causing a right-to-left shunt. POS is most frequently caused by a patent foramen ovale (PFO) and usually, the clinical assessment and a transthoracic echocardiograms with bubble study are enough to reach the diagnosis. The only possible treatment of POS is the percutaneous closure of the defect. We describe two cases of POS due to a PFO which manifested itself years after an episode of acute pulmonary embolism (PE), a finding never reported to date in the literature. Few cases describe the relationship between PE and POS, but these conditions may be more closely related than we currently think.

Progression to a severe form of COVID-19 among patients with chronic respiratory diseases.

RATIONALE: Viral respiratory infections, including SARS-CoV-2 infection, can trigger respiratory symptoms among patients suffering from chronic respiratory diseases, leading to exacerbations and hospitalizations. Despite the tropism of SARS-CoV-2 into the respiratory tract, chronic respiratory diseases do not seem to be risk factors for severe forms of COVID-19. OBJECTIVES: To assess whether hospitalized patients for COVID-19 with chronic respiratory diseases were at lower risk of developing a severe form than other patients. METHODS: This French study included patients admitted to hospital in COVID-19 ward, suffering from a SARS-CoV-2 infection, diagnosed on RT-PCR or chest computed tomography associated with clinical symptoms, from March 15 to June 30, 2020. Ambulatory patients who were tested in the emergency department and patients with severe hypoxaemia requiring intensive care were not included. All data were collected from electronic medical records up to discharge of the patient. MAIN RESULTS: 617 patients were included: 125 with a chronic respiratory disease, mainly chronic obstructive pulmonary disease (45%) and asthma (30%). The percentage of patients scoring 6 or higher on the WHO Clinical Progression Scale during hospital stay was lower in patients with chronic respiratory disease compared to those without chronic respiratory disease (21.6% versus 31.3%, respectively, p = 0.03). Among patients with chronic respiratory disease, temperature above 38 °C on admission (OR 16.88 (95% CI 4.01-71.00)), lymphopenia (OR 5.08 (1.25-20.72)), CPAP therapy (OR 4.46 (1.04-19.17)) and age (OR 1.09 (1.02-1.16)) were associated with an increased risk to reach a score of 6 or above. CONCLUSIONS: Hospital admissions in COVID-19 ward of patients suffering from chronic respiratory diseases are at lower risk of developing a severe form of COVID- 19, especially in patients with chronic obstructive pulmonary disease or asthma. Prospective studies would confirm our results and allow to better organize the follow-up of these patients in a pandemic period.

Impact of Confinement in Patients under Long-Term Noninvasive Ventilation during the First Wave of the SARS-CoV-2 Pandemic: A Remarkable Resilience.

BACKGROUND: During the first wave of the SARS-CoV-2 pandemic in Switzerland, confinement was imposed to limit transmission and protect vulnerable persons. These measures may have had a negative impact on perceived quality of care and symptoms in patients with chronic disorders. OBJECTIVES: To determine whether patients under long-term home noninvasive ventilation (LTHNIV) for chronic respiratory failure (CRF) were negatively affected by the 56-day confinement (March-April 2020). METHODS: A questionnaire-based survey exploring mood disturbances (HAD), symptom scores related to NIV (S3-NIV), and perception of health-care providers during confinement was sent to all patients under LTHNIV followed up by our center. Symptom scores and data obtained by ventilator software were compared between confinement and the 56 days prior to confinement. RESULTS: Of a total of 100 eligible patients, 66 were included (median age: 66 years [IQR: 53-74]): 35 (53%) with restrictive lung disorders, 20 (30%) with OHS or SRBD, and 11 (17%) with COPD or overlap syndrome. Prevalence of anxiety (n = 7; 11%) and depressive (n = 2; 3%) disorders was remarkably low. Symptom scores were slightly higher during confinement although this difference was not clinically relevant. Technical data regarding ventilation, including compliance, did not change. Patients complained of isolation and lack of social contact. They felt supported by their relatives and caregivers but complained of the lack of regular contact and information by health-care professionals. CONCLUSIONS: Patients under LTHNIV for CRF showed a remarkable resilience during the SARS-CoV-2 confinement period. Comments provided may be helpful for managing similar future health-care crises.

Acute Responses to Oxygen Delivery via High Flow Nasal Cannula in Patients with Severe Chronic Obstructive Pulmonary Disease-HFNC and Severe COPD.

Differences in oxygen delivery methods to treat hypoxemia have the potential to worsen CO2 retention in chronic obstructive lung disease (COPD). Oxygen administration using high flow nasal cannula (HFNC) has multiple physiological benefits in treating respiratory failure including reductions in PaCO2 in a flow-dependent manner. We hypothesized that patients with COPD would develop worsening hypercapnia if oxygen fraction was increased without increasing flow rate. We evaluated the acute response to HFNC in subjects with severe COPD when flow remained constant and inspired oxygen was increased. In total, 11 subjects with severe COPD (FEV1 < 50%) on supplemental oxygen with baseline normocapnia (PaCO2 < 45 mm Hg; n = 5) and hypercapnia (PaCO2 ≥ 45 mm Hg; n = 6) were studied. Arterial blood gas responses were studied at three timepoints: Baseline, HFNC at a flow rate of 30 L/min at resting oxygen supplementation for 1 h, and FiO2 30% above baseline with the same flow rate for the next hour. The primary endpoint was the change in PaCO2 from baseline. No significant changes in PaCO2 were noted in response to HFNC applied at baseline FiO2 in the normocapnic and hypercapnic group. At HFNC with FiO2 30% above baseline, the normocapnic group did not show a change in PaCO2 (baseline: 38.9 ± 1.8 mm Hg; HFNC at higher FiO2: 38.8 ± 3.1 mm Hg; p = 0.93), but the hypercapnic group demonstrated significant increase in PaCO2 (baseline: 58.2 ± 9.3 mm Hg; HFNC at higher FiO2: 63.3 ± 10.9 mm Hg; p = 0.025). We observed worsening hypercapnia in severe COPD patients and baseline hypercapnia who received increased oxygen fraction when flow remained constant. These data show the need for careful titration of oxygen therapy in COPD patients, particularly those with baseline hypercapnia when flow rate is unchanged.

[Therapeutic education for people with chronic respiratory disease]. / Éducation thérapeutique des personnes atteintes de maladie respiratoire chronique.

The physiotherapist's practice involves taking care of patients with various chronic pathologies: neurological, rheumatic, respiratory, etc. The physiotherapist must carry out an educational approach in these patients, at the same time as the physical work of re-education, in order to induce behavioural changes beneficial to their physical and psychological health and to empower them in the best possible way in the management of their pathology.

Long-Term Non-invasive Ventilation in Children: Current Use, Indications, and Contraindications.

This review focuses on the delivery of non-invasive ventilation-i.e., intermittent positive-pressure ventilation-in children lasting more than 3 months. Several recent reviews have brought to light a dramatic escalation in the use of long-term non-invasive ventilation in children over the last 30 years. This is due both to the growing number of children receiving care for complex and severe diseases necessitating respiratory support and to the availability of LT-NIV equipment that can be used at home. While significant gaps in availability persist for smaller children and especially infants, home LT-NIV for children with chronic respiratory insufficiency has improved their quality of life and decreased the overall cost of care. While long-term NIV is usually delivered during sleep, it can also be delivered 24 h a day in selected patients. Close collaboration between the hospital complex-care team, the home LT-NIV program, and family caregivers is of the utmost importance for successful home LT-NIV. Long-term NIV is indicated for respiratory disorders responsible for chronic alveolar hypoventilation, with the aim to increase life expectancy and maximize quality of life. LT-NIV is considered for conditions that affect respiratory-muscle performance (alterations in central respiratory drive or neuromuscular function) and/or impose an excessive respiratory load (airway obstruction, lung disease, or chest-wall anomalies). Relative contraindications for LT-NIV include the inability of the local medical infrastructure to support home LT-NIV and poor motivation or inability of the patient/caregivers to cooperate or understand recommendations. Anatomic abnormalities that interfere with interface fitting, inability to protect the lower airways due to excessive airway secretions and/or severely impaired swallowing, or failure of LT-NIV to support respiration can lead to considering invasive ventilation via tracheostomy. Of note, providing home LT-NIV during the COVID 19 pandemic has become more challenging. This is due both to the disruption of medical systems and the fear of contaminating care providers and family with aerosols generated by a patient positive for SARS-CoV-2 during NIV. Delay in initiating LT-NIV, decreased frequency of home visits by the home ventilation program, and decreased availability of polysomnography and oximetry/transcutaneous PCO2 monitoring are observed. Teleconsultations and telemonitoring are being developed to mitigate these challenges.